medic001918

But do we really need a new thread for every episode? Shane NREMT-P

As far as the oxygen delivery for a COPD patient and hypoxic drive, it takes several hours (I believe there was a study that showed the time to be in excess of 12 hours) to kick in and should not be a consideration for prehospital care. And on to this statement. Like someone mentioned, this guy was an idiot before he became a paramedic. And don't forget that there are just as many paramedics that don't like EMT's because they tend to think they know everything as well. I've seen many new EMT's come in thinking they know it all, have seen it all and done it all...even though the ink isn't dry on their certification yet. As a paramedic, that attitude gets old as well. In this case, you were right. Remember, people who think they know it all happen on both sides of the coin. Give respect and get it. Shane NREMT-P

+1 for a well written post that clearly explains Glucagon, how it works and why it shouldn't be given by basics based on their current level of training. Shane NREMT-P

How could one assume that it's not a trauma? It's a CYA issue in this case. There doesn't appear to be anyone around to tell you a story. And traumatic injury can't be ruled out, so c-spine precautions would be initiated. As far as the delta thing, we commonly use plain english at the service that I work for so I'm not familiar with the definitions. Just a difference in area I guess. I'd like to hear some information regarding the questions from assessment...we'll see where it goes from here. Shane NREMT-P

I'll assume a "delta" response is an MVC of some kind? Remember when posting scenarios that we don't all follow codes, or the same codes for that matter. But I'll give the scenario a go. If the patient is cyanotic and not breathing, but has palpable pulses, then airway is among the highest priority while preserving c-spine precautions. The patient is lying in a ditch, but is he lying prone? Supine? If he's prone, we'll log roll him while manually holding c-spine. Once the patient is supine, it's time to correct the issue of him not breathing by bagging via BVM with O2 along with the use of an OPA. The cyanosis and lack of respiratory effort would is of major concern and indicative of the need for intubation. Are there any secretions in the airway that we need to suction? The patient would immediately be intubated assuming adequate relaxation and someone manually holding c-spine during the intubation attempt. Once my airway is secure, the patient would be ventilated at a rate of approximately 12 breaths/min. What do the patients lungs sound like? Are they equal? Clear? Adventitious? The patient would be exposed to look for any obvious injury and log rolled onto an LSB. The monitor would be applied to the patient, so I'd like to know what rythem I see? Along with a full set of vital signs including blood glucose, pulse oximetry and ETCO2? Is the patients color improving after being intubated? It's time to get going to the hospital on a priority transport. En route, I'd establish at least one IV w/fluids hanging at KVO (unless something indicates otherwise). I would try for a second point of IV access if time allowed and the patients condition remained without change. At this point, further assessment and supportive care would be indicated. Also, as a side note of a truama center being 16 mintues away, lifeflight would not even be a consideration as it would only serve to delay getting the patient to definitive care, especially since there are no difficulties with extended extrication. Ground transport on a priority to the trauma center would be adequate for this patient. Shane NREMT-P

+1. A great read and a good story that we can learn something other than just medicine from our patients. We are fortunate to have the opportunities that we do to encounter so many people and hear their stories. A great, well written article as usual by Dr. Bledsoe. Shane NREMT-P

I'm with those that say that you can't over dress for an interview. You want to put forth your best image. Regardless of the kind of work you will be doing, an interview is (or should be) a formal process and one that should have a formal dress with it as well. I just recently picked up a per diem position at another service in my area. I was one of three prospective employees that interviewed wearing a full suit. I'm also one of the few people that got hired by the service. I went in with the intent to make a good, positive impression. One that showed that I am willing to take the position, my representation, and most importantly the representation of the service seriously. Don't try to get by with the minimum required. If an employer is going to not view you as a good candidate for being "overdressed" for an interview, are they really the kind of service you want to represent? In some ways, I'm surprised that people feel the need to ask what to wear to an interview. I always thought it was standard practice to dress professionally for one unless they state to bring clothes to perform certain tasks in (such as an agility exam). Typically on the day of the interview, the interview is all that will be happening. Good luck. Shane NREMT-P

I want to know a little more about what she ate as well. Did she make something new that she hadn't eaten before? As far as management of the seizure, I'd give versed IM or ativan IV depending on if she had access. The story is consistent with a seizure, but we have to figure out why. What do her pupils look like? Is there any indication of a bleed? Any chance of any head trauma during their trip? As far as care and management of the patient, high flow oxygen via NRB, suction the airway of the secretions if needed. At the minimum this patient is a candidate for an NPA, possibly a candidate for intubation if she continues to seize. Secure IV access to allow for medication administration and definatly monitor the cardiac rythem for any underlying rythem disturbance. My guess is there's more to the story then what the boyfriend is letting on. Also, let's not forget to consider some spinal immobilization precaution. She did fall due to a suspected seizure and she's not totally oriented which in my PSA rules out the ability to clear her c-spine. Shane NREMT-P

Sounds very much like an internship or preceptorship. And they typically require a documented reason for failure. More than just because the preceptor didn't like him. Still doesn't sound like we have the complete story yet. Shane NREMT-P

I'm not so sure that he would have been failed just because the preceptor didn't like him. Commonly they need to document a reason for failure. Something just doesn't sound right in this case. My guess is something might have happened that he hasn't told you about. Shane NREMT-P

I wasn't making a general comparison to the rest of the healthcare profession, but with regard to where we function in the prehospital enviornment a paramedic is far more educatated than an EMT-B. I'm in favor of raising the educational requirements for ALL levels of prehospital providers. Shane NREMT-P

Basics are not stupid people, but they are limited by a very narrow window of education that largely leaves them underprepared for work in the field. Consider the curriculum and material covered in the current EMT-B program. Most new basics have a hard time determining when they really need ALS. Instead of viewing an EMT-B as a paramedic assistant, maybe they would be best served to focus at becoming profecient in their own skill set and knowledge base. The biggest difference an EMT and a paramedic is the knowledge behind the assessment. If any new EMT really wants to become proficient, take a couple semester of A&P and learn to assess your patients adequately. Then you'll truely be doing them a greater service. Shane NREMT-P

That's nice that you can use weather it's proper context. Look up "our" and "are" in the dictionary, as the two words are grossly dissimlar. Looks like we're even, doesn't it? Shane NREMT-P

I can understand a patient looking for a familiar face in their time of need, but they also need to understand that they're not guaranteed to have people they know on the ambulance. I'm not sure how I would react to a patient questioning me with a question like "who are you and how long have you lived here?" Who I am...sure, I'll tell you who I am and what I do. But a "how long have you lived here" question is 100% irrelevant to the call or my ability to provide the emergency care you requested or required. My thread hijack is over... On to the topic, someone probably made a poor decision in requesting that the FD not be sent to the calls; especially if they are closer most of the time. My initial thought was that the FD is no longer toned because they were the paramedic provider in the area which was taken over by the ambulance service. That doesn't appear to be the case. I have to agree that it's probably a bad idea to get involved in the politics of the decision. And as a side note, and possibly another topic...do we do patients any good by having so many different providers on an emergency scene? Here's an example from the service I work in. It's not uncommon to have a BLS engine first respond, a transporting ambulance, at least one (usually two) police officers, and depending on the location of the call an intercept paramedic unit. So let's go on the short side and say it's a 3 person engine (usually 4-5 people though), two police officers, two members from the ambulance crew and one intercept paramedic (even if the transporting ambulance is an ALS unit). That's a minimum of 8 different people coming to someone's house for one medical call. Is this really the most effective use of resources? And does it really provide any level of benefit for the patient? Something to think about... Shane NREMT-P

Your post is poorly written(at best) and difficult to follow and really doesn't contribute anything to the topic. So let's just clarify something, you work with paramedics but you're not one yourself? Just trying to get a feel for the level of care YOU provide. That tends to lend itself rather well to understanding where someone is coming from in their views. As a paramedic, I probably look at calls and situations differently than an EMT simply do to training and the higher thought process involved. It's not a bash, just tryng to understand. Noone here has claimed or acted like a paragod. This scenario turned into a discussion of weather to work certain cardiac arrests. You've asked what our protocols state and that has been answered by many experienced paramedics here. Their answers have not been study based, rather protocol based...as per your request. Please, explain your last post and where you going with it...I'm left confused by where it came from as I'm sure others most likely are too. Shane NREMT-P

What do my protocols state? My protocols state to not initiate efforts on a patient with obvious death to start. And they also state that I don't have to transport an asystolic arrest after intubation, IV access, 3 rounds of meds and 20 minutues of effort without change. Dead people are dead and stay that way. It's a risk to the safety of the crew to transport someone who isn't a viable patient. It simply prolongs the death process. And it's a poor use of resources since that's an ambulance out of service for no real valid reason. And your logic about paramedic "sucking" at intubation are hardly validated. Great strides have been made to help assure that misplaced/displaced tubes are properly detected in the way of end tidal CO2 monitoring. My particular service actually maintains a very high sucess rate with intubation and we have the option of requesting OR time if we want it though our medical control. The skill of intubation itself isn't rocket science at all. In fact, it's a pretty straight forward and easy skill. The knowledge of when and why to perform it is more important. Some patients are better off not being intubated or intubated after other meaures have been exhausted. There is a considerable thought process in intubating someone, the least of which is the skill itself. Shane NREMT-P

Your teacher anaolgy just might provide the answer to the problem. In order to effectively staff the schools, they combine school districts together in one school to allow for degreed teachers rather then lowering the standards. Instead of telling your citizens that they need to absorb the entire cost, spread the cost among a district and provide a paramedic intercept response for a region instead of an isolated town. While this might not mean the paramedic is always available, the availability should be better than not having one at all within 30 minutes. But I suppose that all in all it comes down to what the citizens of any given area are willing to pay for and willing to accept as a standard level of service. Sometimes it's better for towns to combine resources in order to better serve the greater number of people. Shane NREMT-P

Now that I've read the post through some rested eyes and gotten some more information, it's a little easier to totally understand the scenario. I agree that at a rate of 175 BPM it will be hard to tell v-tach from SVT. The advice that has been given so far has been very good advice. "Defib to stop the tachycardia, consider an antidysrhythmic to keep it slowed down, replace volume, look for ECG changes and drug use history." posted by AZCEP is excellent advice with great prioritization of interventions in this case. I don't think the chances of finding a patient in a rythem as described is very likely at all. But we can all appreciate the thought process behind your question and wanting to know more. Good for you for wanting to expand your knowledge as much as possible. Keep up the good work. Shane NRMET-P

A tachy rhythm that doesn't produce a pulse would still be considered a PEA, although an extremely fast rhythm that doesn't have a pulse is most commonly ventricular in nature. Remember that the goal is to treat the underlying rhythm...whatever it may be. If someone's in a wide complex, fast rhythm such as pulseless v-tach then you want to treat the v-tach. If someone is pulseless, then treat the patient as a cardiac arrest...and this includes the cardiac arrest medications. Epi is a front line medication in all arrests (that i can think of right now) and should be used first. Don't forget to use your electricity in tachy rhythms, especially pulseless ones as long as the shock is indicated. Again pulseless v-tach should be shocked before anything else occurs. I can't ever recall finding a patient in a tachy rhythm over 150 BPM that didn't have a pulse to it unless it was ventricular in nature. Look to your underlying rhythm and treat it accordingly and you will be fine. Hope some of this made sense...it's kind of late and I'm rather tired. So if it didn't, I apologize. Shane NREMT-P

The decision of where to work is yours. It depends more on the service than the location as far as being new goes. The biggest thing that i could recommend would be to work somewhere that you are geographically familiar with if possible. There isn't much wose than needing to be at a hospital with a patient that demands my full attention and having to give directions at every intersection, stoplight, stop sign, etc. The cities tend to have more call volume, but they also tend to do more calls that don't amount to much...drunks, cold and flu, etc. These calls are valuable though to someone new to the field in that it's a chance to improve your patient interaction and assessment skills. So once again, there's a value there. As far as city employees not liking "young newbies," it has nothing to do with being in a city. It has everything to do with the person. Your attitude will go a very long way towards how your coworkers percieve you. Ask questions that are pertinent. Don't get into a game of comparing war stories. Be open to criticism. The criticism should be of the constructive variety though, not the degrading kind. Be open to suggestions. Ask how you can improve. If my partner is new and takes an active interest in learning, I don't mind teaching them. If my partner is new and comes in with an attitude that they have seen and/or done it all, or the attitude that they already know everything they need to know...then they are in for a large reality check. I'll go out of my way to help you if you desire the help. If you're going to ask and not listen, I'm not going to waste my time. Be honest about your experiences (or lack of), and you'll find that you are rewarded with more assitance then you know what to do with. Lie and find out how quickly you get left with just enough rope to hang yourself. It has the potential to be a vicious field. While most calls are not life threatening, there are those that are and it's not the time to deal with someone's attitude unless they can 110% back it up. Keep an open mind and a thick skin and you'll be fine. It's more how you act than your physical age. Good luck, Shane NREMT-P

I wouldn't go as far as saying that the people here are the type to not let a new person in out of fear that you might pick something up quicker than we did. There are many experienced providers here, but there also many inexperienced ones who try to play off having more experience/education then they really do. Like someone else mentioned, a truly experienced provider in the field can see through this really easily. The moment you try it, you end up discrediting yourself. Many people here have already demonstrated their knowledge and experience over time. The longer you stay and read, the more you'll pick up on who's experienced and reliable with their information. I stayed out of this scenario, mostly because it was difficult to follow. This makes it difficult to respond with any accuracy and to make it an educational experience for anyone. A true scenario starts and flows until the end. It doesn't get "edited" repeatedly or have stories change. These frustrate other posters easily and again causes you to discredit yourself. As far as not being able to "grasp the text," maybe that's something you should look to yourself to correct? It seems to me that we can all read and understand English. Using proper grammar, rereading your posts and using spell checker will go a long way to making an intelligent sounding post that can be followed by many people with a grade school education. If the majority of people are having a problem understanding your post, do you really think that all of them are the problem? Or is it the post itself? Look at the common denominator...the post. Post intelligently and with thought, and we'll all follow along and we just might be able to learn from one another. Remember, on an internet forum your written/typed word is as good as your spoken word in person. Take pride in what you say and say it correctly. After all, we are all supposed to be healthcare professionals. Thanks for finally clarifying your level of certification. It goes a long way to understanding what you might or might know as common knowledge. As far as Dust telling you what he feels about EMT's, that's his opinion. It doesn't matter what anyone else thinks. If you don't take pride in your level of care, who is going to do so? While not being a big fan of the EMT-B curriculum myself, I'm not going to discredit anyone who took the course and obtained the certification. It is what it is...a relatively short and easy course that provides a minimal (at best) base knowledge to be a pre hospital provider. Should the course be more than what it is? Yes. Would that go a long way towards an EMT-B being respected by others in the field? Probably. But those are both topics for another thread that have already been discussed. Be proud of what you've become and take pride in yourself and your position. You'll find people just might be more tolerant of errors and be willing to discuss a topic intelligently and with the intent of educating you. Good luck, Shane NREMT-P

I'm not going to recommend the "just showing up" route, but I would recommend calling the HR department for the division you've applied to and checking on the status of your process. You just might find your answer that way. Take some initative and put in some effort, and you will probably get the rewards that you desire. Following up shows that you are interested and truely want the position. Shane NREMT-P

+1. No sense if losing sleep or getting bothered by something that you can't change in the first place. As much as I dislike these calls, they are part of the job. The nice thing is that they can often times be turned around very quickly and get you back into service. Pick your battles, and this one wouldn't be worth fighting in my opinion. As 8 mentioned, patterns repeat themselves. Shane NREMT-P

I agree for the most part with the posts above. Study A&P, and specifically the respiratory, cardiac and nervous systems. These are the systems we depend on the most and need to have a very solid grasp of when it comes to understanding. As far as pharmacology, I've found that the secret to really understanding pharmacology is to understand how the nervous system works since many of the medications we use work primarily on the nervous system. This understanding will make it far easier to remember the side effects and actions of the medications. Shane NREMT-P

My guess is that like most things in medicine, not everyone subscribes to the theory. It may be your medical directors feeling that trauma patients should still be aggressively resuccitated with fluids. Our protocols are pretty generous and allow us some flexibility. Like your old medical director, if they need fluid we can give it to them. But noone is going to come on a head hunt for us if we chose to allow some degree of hypotension. The more I've read about hypotension, the more I've come to think that's the direction we should be going until we start carrying products that allow some form of oxygen carrying capacity. Putting large qualities of NS or LR on a patient does nothing for their ability to perfuse the organs with the oxygen they require. Shane NREMT-P